Enhabit Home Health

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and interview, the agency administered services without a physician or allowed practitioner order for laboratory testing of urine for 1 (#6) of 2 records reviewed where laboratory testing was done on a urine specimen. The failure placed the clients at risk for unnecessary medical interventions, emotional distress, and financial burden. Patient #6: Record review of Patient #6’s Patient record revealed a Plan of Care dated 4/6/2024 to 6/4/2024. The Plan of Care indicated that Patient #6 was admitted to the agency’s services on 4/6/2024. The Plan of Care listed Chronic Venous Hypertension with Ulcer of Left Lower Extremity (condition where high blood pressure in the leg veins can cause open sores to the legs) as the primary diagnosis. Registered Nurse C conducted a skilled nurse visit on 5/1/2024. Registered Nurse C documented that Patient #6 had urinary incontinence (unable to control urine output from the bladder) during the daytime and at nighttime. Registered Nurse C documented that a urine was collected because Patient #6’s urine was cloudy and had a foul smell. Registered Nurse C documented that the urine was taken to a laboratory for urinalysis and culture/sensitivity (bacteria that caused infection would be identified and medication that would be effective for treatment). Registered Nurse C documented that the physician’s office was called to get orders but closed at 3:00 p.m. Registered Nurse C documented that Patient #6’s spouse would get in touch with the physician and get orders sent to the home health agency. Patient #6’s clinical record did not contain a physician order for laboratory testing of Patient #6’s urine. During an interview on 12/16/2024 at 1:26 p.m. with the Administrator and Supervising Nurse, the surveyor discussed that Registered Nurse C had obtained a urine specimen and sent it for laboratory testing but there was no physician order for testing Patient #6’s urine. The surveyor discussed that Registered Nurse C documented that Registered Nurse C did not have a physician order. The surveyor asked what the agency’s policy on documentation of physician’s orders was. The Administrator stated, “We document them when we receive them.” The Administrator informed the surveyor that the Administrator would review Patient #6’s record. The surveyor requested the agency’s policies regarding obtaining physician orders for laboratory testing. The Administrator informed the surveyor that the S02, (Admission Process and Patient Assessment -HH Only) policy at 3.2 was the agency’s policy regarding obtaining physician orders. The Administrator and surveyor reviewed the policy. The surveyor asked was this policy only for physician orders at admission, due to the title of the policy. The Administrator informed the surveyor the policy was not just for obtaining orders at admission. The Administrator informed the surveyor the verbiage, “any services” referenced in the policy at 3.2 would include laboratory services. During an interview on 12/17/2024 at 11:31 p.m. with the Administrator, the Administrator informed the surveyor that the Administrator spoke with Registered Nurse C about the urine specimen obtained without a physician’s order. The Administrator informed the surveyor that Registered Nurse C admitted obtaining the urine specimen without an order. The Administrator informed the surveyor that Registered Nurse C had told the Administrator that Registered Nurse C was just trying to help the patient. During an interview on 12/17/2024 at 12:09 p.m. with Registered Nurse C, the surveyor discussed Patient #6 and the urine specimen obtained for laboratory testing. The surveyor asked if Registered Nurse C had obtained an order for the urine from the physician. Registered Nurse C stated, “I don’t remember getting the order for the urine, it had been a while.” The surveyor asked where Registered Nurse C had taken the urine. Registered Nurse C stated, “To [name of laboratory].” Review of the agency’s policy titled’ Admission Process and Patient Assessment (HH Only), labeled S02, and with original issue date 01/ 2000, and a revised date of 11/25/2024, read in part: “1.0 Purpose...1.2 Establish a clear sequence of events in the intake and admission process to confirm appropriate services and timely start of care...3.0 Policy...3.2 The Agency follows established procedures for 3.2.1 Accepting and evaluating referral information. 3.2.2 Consulting with the physician and obtaining a verbal or written order for start of care and any services. Verbal orders will be considered updates to the Plan of Care. 3.2.3 Coordinating timely service delivery, including communication to appropriate staff members...””

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review and interview, the agency failed to send a completed discharge summary to the primary care practitioner or other health care professional that would be responsible for providing care and services to the patients within 5 business days of the patients’ discharge from the agency for 6 (#2, #3, #4, #5, #6, #7) of 6 discharged patient records reviewed. The failure placed the patients at risk of disruption in the continuity of care, delayed or incorrect treatment, and increased risk of readmission to the hospital. Review of the Texas Unified Licensing Information Portal listed the agency’s operating days as Monday through Friday. Patient #2: Record review of Patient #2’s clinical record revealed a Plan of Care dated 3/25/2024 to 5/23/2024. The Plan of Care indicated Patient #2 was admitted to the agency’s services on 3/25/2024. The Plan of Care listed Unspecified Dementia, Moderate (group of brain disorders that cause a progressive decline in cognitive function, memory, thinking, and behavior) as the primary diagnosis. Physical Therapist D conducted a discharge comprehensive assessment on 4/29/2024. Physical Therapist D documented Patient #2 was discharged on 4/29/2024. Patient #2’s record contained a discharge summary (unsigned) that indicated Patient #2 was discharged due to no longer requiring skilled care on 4/29/2024. The discharge summary contained documentation that the discharge summary was sent to a Nurse Practitioner on 5/8/2024, 7 business days after Patient #2 was discharged from the agency. Patient #3: Record review of Patient #3’s clinical record contained a Plan of Care dated 8/15/2024 to 10/13/2024. The Plan of Care indicated that Patient #2 was admitted to the agency’s services on 8/15/2024. The Plan of Care listed Unspecified Dementia, Mild (group of brain disorders that cause a progressive decline in cognitive function, memory, thinking, and behavior) as the primary diagnosis. Registered Nurse E conducted a discharge comprehensive assessment on 9/26/2024. Registered Nurse E documented that Patient #3 was discharged on 9/26/2024. Patient #3’s record contained a discharge summary (unsigned) indicated that Patient #3 was discharged on 9/26/2024 due to goals were met. The discharge summary contained documentation that the discharge summary was sent to a Nurse Practitioner on 10/11/2024,11 business days after Patient #3 was discharged from the agency. Patient #4: Record review of Patient #4’s clinical record revealed a Plan of Care dated 12/18/2023 to 2/15/2024. The Plan of Care indicated that Patient #4 was admitted to the agency’s services on 10/19/2023. The Plan of Care list Aphasia following Cerebral Infarction (language impairment resulting from a stroke) as the primary diagnosis. Speech Therapist F documented a discharge data-collection-only note on 2/15/2024. Speech Therapist F documented that Patient #4 was discharged from the agency on 2/15/2024. Patient #4’s record contained a discharge summary (unsigned) that indicated Patient #4 was discharged on 2/15/2024 due to non-compliance. The discharge summary contained documentation that the discharge summary was sent to a Nurse Practitioner on 2/26/2024, 7 business days after Patient #4 was discharged from the agency. Patient #5: Record review of Patient #5’s clinical record revealed a Plan of Care dated 10/15/2024 to 12/13/2024. The Plan of Care indicated that Patient #5 was admitted to the agency’s services on 10/15/2024. The Plan of Care listed Age-Related Physical Debility (condition of being weak and delicate due to aging) as the primary diagnosis. Registered Nurse E documented a discharge data-collection-only note on 11/14/2024. Registered Nurse E documented that Patient #5 was discharged on 11/8/2024. Patient #5’s clinical record contained a discharge summary (unsigned) that indicated that Patient #5 was discharged on 11/14/2024 due to Patient #5 no longer required skilled care. The discharge summary contained documentation that the discharge summary was sent to a Physician on 11/21/2024, 8 business days after Patient #5 was discharged from the agency. Patient #6: Record review of Patient #6’s clinical record revealed a Plan of Care dated 4/6/2024 to 6/4/2024. The Plan of Care indicated that Patient #6 was admitted to the agency on 4/6/2024. The Plan of Care listed Chronic Venous Hypertension with Ulcer of the Left Lower Extremity (condition where high blood pressure in the leg veins can cause open sores to the legs) as the primary diagnosis. Patient #6’s record contained a discharge summary (unsigned) that indicated that Patient #6 was discharged to hospice on 5/7/2024. The discharge summary contained documentation that the summary was sent to a Physician on 5/15/2024, 6 business days after Patient #5 was discharged from the agency. Patient #7: Record review of Patient #7’s clinical record revealed a Plan of Care dated 3/8/2024 to 5/6/2024. The Plan of Care indicated that Patient #7 was admitted to the agency’s services on 3/8/2024. The Plan of Care listed Primary Generalized Osteoarthritis (chronic joint disease causin breakdown of the smooth protective tissue that covers the ends of bone in multiple joints) as the primary diagnosis. Physical Therapist G conducted a discharge comprehensive assessment on 5/2/2024. Physical Therapist G documented that Patient #7 was discharged on 5/2/2024. Patient #7’s record contained a discharge summary (unsigned) that indicated Patient #7 was discharged because goals were met on 5/2/2024. The discharge summary contained documentation that the discharge summary was sent to the Physician on 6/7/2024, 25 business days after Patient #7 was discharged. During an interview on 12/16/2024 at 1:26 p.m. with the Administrator and Supervising Nurse (date of hire 11/4/2024), the surveyor discussed the discharge summaries were not sent, within 5 business days after the patients were discharged from the agency, to the health care professionals that would be responsible for providing care/services to the patients after discharge. The surveyor asked the process for sending the discharge summaries. The Administrator informed the surveyor that a medical records specialist would send the summaries. The surveyor asked how medical records would know to send a discharge summary. The Administrator stated, “It would go to their workflow after the discharge has been processed. The surveyor asked who processed the discharges. The Administrator informed the surveyor that the Branch Director or Administrator would process the discharges. The surveyor asked what the agency’s timeframe was to send the discharge summaries. The Administrator stated, “5 days.” The Administrator informed the surveyor that the discharge summaries were printed and given to the Hospital/Clinic System liaison (an employee of the home health agency) and the liaison would take them to the Hospital/Clinic System. The Administrator informed the surveyor that the clinicians document the discharges by the end of the day or next morning. A scheduler tracks for outstanding documentation and would email the clinician, Branch Director, and the Administrator for follow-up. The Administrator and Supervising Nurse did not dispute the finding. Review of the agency’s policy titled ‘Transfer or Discharge From Services (HH Only),” labeled S12, with a reviewed date of 10/18/2023, and revision date of 8/5/2024, read in part; “1.0 Purpose 1.1 Establish guidelines which confirm the safe, timely and appropriate discontinuation of homecare services...Policy...3.3.4 The Appropriate licensed professional obtains an order for discharge or documents physician notification and provides discharge instructions to the patient in writing. A Discharge Summary is completed and sent to the physician within 5 business days...””